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Florida Department of Agriculture and Consumer Services

NICOLE "NIKKI" FRIED, Commissioner
Section 487.046(1), F.S., and Rule 5E-9.026 F.A.C.
Applicant must be 18 years of age or older to apply. Provide the details below. Fields marked with red asterisk are required. (Date Format: mm/dd/yyyy, Phone Format: 999-999-9999)
Applicant Information
Name of Company or Individual Requesting License: * Email: *
Business Phone: Cell Phone: Home Phone: Fax Number:
Applicant Address
Business Address: * Line 2: Business City: * State: * Zip Code: *
Mailing (if different): Line 2: Mailing City: State: Zip Code:
Home Address: Line 2: Home City: State: Zip Code:
Authorized Agent Information
First Name: * Middle Name: Last Name: *
Date of Birth: * Title: